Wed10November0747AM 7

A 63-year-old man is admitted to the medical admissions unit with a haemorrhagic stroke.

He has been on warfarin therapy for longstanding atrial fibrillation. His INR on admission is 9.1.

Which one of the following options is the single best management or treatment choice?

(Please select 1 option)

Stop warfarin for five days

Recombinant factor VIIa

Fresh frozen plasma

Prothrombin complex concentrate Correct

Vitamin K

Explanation

Haemorrhage, including intracranial bleeding, is a common, potentially lethal complication of warfarin therapy and rapid and complete reversal of anticoagulation may be life saving. Clotting factor concentrates are the only effective option where complete and immediate correction of the coagulation defect is indicated in orally anticoagulated patients with life or limb-threatening haemorrhage.

Prothrombin complex concentrates (PCC) are recommended for rapid reversal of vitamin K anticoagulants. They are derived from human plasma and contain the vitamin K dependent clotting factors II, VII, IX and X. As they normalise levels of vitamin K dependent clotting factors and re-establish haemostasis, they may also be used as adjunctive therapy in patients with major bleeding.

Fresh frozen plasma (FFP) and vitamin K are most frequently administered. Because of the variable content of vitamin K-dependent clotting factors in FFP, and the effects of dilution, the efficacy of this approach is open to doubt. Other potential problems include significant intravascular volume challenge, and the possibility of rare complications such as transfusion-associated lung injury or blood-borne infection.

Vitamin K should be administered by slow intravenous infusion over 30 minutes to avoid potential anaphylactic reactions. The reversal of INRs with vitamin K can take 24 hours to exert its maximal effect regardless of route of administration.

Use of factor VIIa (recombinant) may be considered for reversal of anticoagulation in patients with warfarin-associated intracranial haemorrhage but its use is controversial. There are questions related to the assessment of efficacy in changes in the INR and there are concerns regarding thromboembolic events following treatment. However, if administration is considered, patients should be screened for increased risk of thrombosis before administration of the drug.

Answer Statistics

1

1%

2

2%

3

3%

4

94%

5

3%

Times answered: 282